Welcome to our Energize questionnaire

Please can you fill out the form below so we can get a better understanding of your background?

Your Name (required)

Your Email (required)

Your Telephone(required)

Date of Birth (required)

Do you suffer from any of the following? Press CTRL to select more than one:

Have you ever had surgery? If so, give a short summary of the (required)

Do you suffer from back pain? If so, give details: (required)

Any health challenges that might prevent exercise? (required)

Please list any medication that you are currently taking: (required)

Have any of your parents/grandparents experienced the following conditions? Press CTRL to select more than one:

Do you have any children? (required)

Details of Births (required)

Do you smoke? (required)

If yes, how many per day (required)

Weight (required)

Height (required)

BMI(required)

CONFIDENTIAL LIFESTYLE QUESTIONNAIRE

How many hours a day do you spend SITTNG in front of TV, a computer, at work? Explain: (required)

On a scale of 1 to 10 (1=not active, 10=very active) please rate how active you are on a daily basis? (required)

How many hours of sleep do you get every day? Notes about your sleep: (required)

Do you consider yourself to be under stress? If yes, provide details: (required)

Are you currently involved in any exercise programme? If yes, please list how long and what type of exercises. Please list them and say how long you’ve been doing these exercises?

Do you follow, or have you recently followed, any specific dietary intake plan and, in general, how do you feel about your nutritional habits? Do you wish you could change these?

Daily Dietary Intake

No. of cups of coffee (required)

No. of cups of tea (required)

Glasses of Coke/Soda(required)

Glasses of milk (required)

Glasses of water (required)

Biscuits/cakes(required)

Chocolates (required)

Sweets (required)

Alcohol (required)

Fast food (required)

Take-away food (required)

Portions of fruit(required)

Portions of vegetables (required)

Are you a Vegetarian? (required)

Do you have any Dietary restraints?(required)

24 hour recall – Dietary intake and physical output: (Note to retreaters, can you give me a 24 recall on your intake and output the day you complete this form. Rely on your memory!)

Please list THREE goals in order of importance:

All information on this form is correct to the best of my knowledge. I understand that this information is confidential and solely between myself (the client) and Yvonne Wake (lifestyle counsellor). The purpose for my involvement is to learn more about Nutrition, Wellbeing, Lifestyle, and how to live a healthier life. Any advice or information that I take from this will be my own responsibility. I agree that Yvonne Wake has taken every care in giving out advice on my particular lifestyle but that she assumes no responsibility or liability for any harm as a result of any information obtained within the consultation period. This is a commitment between myself and Yvonne Wake.